Before we get started—this sucks.
This situation seems like an unnecessarily long and painful runaround for something that appears to be medically necessary and should have been covered by Aurora’s health plan based off the information provided in the video. Unfortunately, the plan structure her employer is using seems to have introduced a few complications (on top of a really odd denial from the start).
If you’re in a similar situation—or just want to understand what went wrong—here’s what likely happened based on the TikTok and what next steps could be.
Why I Know What I’m Talking About
I’m a licensed health insurance broker in all 50 states and have been helping small businesses offer health benefits for the last ~10 years. I’m also the cofounder of a company called StretchDollar, where we help employers set up plans where this does not happen, thanks to some regulatory protections (more on that later).
What (we think) happened here:
Prior auth gone wrong
Case reviews for expensive surgeries are common, but we’ve never heard of a carrier outright fabricating a medical opinion. Honestly, it sounds almost like an AI hallucination (yes, some carriers have used AI to deny claims and it has not been going well).
As frustrating as this process is, Aurora did the right thing by contesting the prior authorization denial. When in doubt, always ask your insurance company to show its work.
Murky plan structure
Self-funded and level-funded plans have become increasingly popular among employers as a way to reduce monthly premium costs by taking on some of the group’s risk. In this setup, Cigna isn’t technically the insurer—they’re a third-party administrator (TPA) managing claims on behalf of the employer’s plan.
This is an alternative of traditional “fully insured” group and individual plans, which offer more patient-facing guarantees. Level-funded plans are regulated federally under ERISA, while fully insured plans are regulated at both the state and federal levels.
Personally, I’m not a fan. These plans can save employers money but people often don’t understand the risks they’re incurring in exchange.
They’ve become so widespread in the industry that we’ve met several employers who didn’t even realize that the benefits they were offering were through a level funded vehicle vs. the fully insured one they were expecting.
Pro Tip: Ask your employer what type of coverage they’re offering (self-funded, level-funded, or fully insured). If they don’t know, request an introduction to their broker.
Unclear support lines
Legally, it’s the responsibility of the health insurance broker here to have helped Aurora navigate this entire process and it sounds like they were the last to pick up the phone. Always know who the broker is for your health insurance policy—they’re specifically trained and licensed to assist in these situations, unlike your employer or HR department.
Not sure who your broker is? Ask HR or your boss—they can help facilitate an introduction.
What to do next
Contact your employer
Cigna, being the TPA in this event, is likely the organization that denied the claim on behalf of the employer’s level funded plan. There are certain scenarios where an employer can override a claim denial (granted, it doesn’t often happen but it’s worth a shot).
At the very least, if you find yourself in a similar position, your employer should be aware that their TPA is denying claims without providing proper medical reasoning.
File an ERISA complaint against the TPA
Because level-funded plans fall under federal ERISA rules, the most effective way to escalate is by filing an ERISA complaint. It’s not as scary as it sounds—essentially, it’s a formal way of saying: ‘My plan administrator didn’t follow the rules.’
Filing a complaint might feel daunting, especially since your employer could end up footing the bill for the care they promised to provide. But remember: federal law protects you from any retaliation.
Disclaimer: This is just my two cents based on the info provided and my experience in the health insurance world. I wasn’t in the room where it happened (cue the Hamilton soundtrack), so take this as friendly advice, not gospel truth. Always consult your broker or a trusted expert for your specific situation!
